Aim of the Study: This study aimed to evaluate the prevalence of loneliness and its relationship with social connectedness and depression in elderly. Additional aims were to evaluate the demographic and clinical factors associated with loneliness and social connectedness in elderly patients with depression. Methodology: The study sample comprised 488 elderly patients (age ≥60 years) with depression recruited across 8 centers. These patients were evaluated on Geriatric Depression Scale (GDS-30), Generalized Anxiety Disorder-7 Scale (GAD-7), Patient Health Questionnaire-15 (PHQ-15) Scale, Columbia Suicide Severity Rating Scale, UCLA Loneliness Scale (LS), and Revised Social Connectedness Scale. Results: About three-fourth (77.3%) of the entire sample reported the presence of loneliness. With respect to specific loneliness symptom, 62.5% reported lack of companionship, 58.7% reported being left out in life, and 56.5% of the individuals reported felt isolated from others. No gender differences were noted in the prevalence of any loneliness symptom. Higher loneliness scores had significant positive correlation with severity of depression, anxiety, and somatic symptoms as assessed by GDS-30, PHQ-15, and GAD-7, respectively, in individuals of both the genders. Higher social connectedness was associated with higher level of anxiety and lower loneliness in females only. Being currently single, older age, longer duration of illness, presence of family history of mental illness, presence of comorbid physical illness, and absence of substance abuse were associated with higher loneliness. With regard to suicidality, higher loneliness was associated with nonspecific active suicidal thoughts, active suicidal ideations with and without intent, nonsuicidal behavior, and higher intensity of suicidal ideations. Conclusions: About three-fourth of the elderly patients with depression also have associated loneliness. Loneliness is associated with higher severity of depression, anxiety, and somatic symptoms. Severity of depression is associated with loneliness but not with social connectedness. Lower social connectedness among elderly females with depression is associated with higher loneliness, but this is not true for elderly males with depression.

Loneliness in humans has been understood as a discrepancy between desired and real social relations[1] and the impact of loneliness over physical and mental health has been evaluated in many studies across the globe.[2] Data from the Western countries suggest that although loneliness is prevalent across all age groups, it is more distinctive in the geriatric population.[3],[4] Based on the three-item version of the UCLA Loneliness Scale (LS) studies from Western countries have estimated the prevalence of chronic loneliness in individuals aged ≥60 years to be in the range of 11.5%–43%[5],[6] It is suggested that as the age advances, elderly persons often tend to lose the active role they used to play and enter into a passive role which makes them feel insufficient and they develop a sense of alienation and a sense of losing independence and resultant loneliness.[7],[8],[9] Available data also suggest that aging alone is not responsible for developing feelings of loneliness,[4] rather several other factors such as gender, marital status, level of education, being employed or not or being financially stable or not, and living environment also play a significant role in the development of loneliness in elderly individuals.[10]

It is now a well-known fact that the number of elderly people living alone is increasing all over the world.[11] This can be understood from the fact that in the United Kingdom, the government has formed a ministry for loneliness.[12] Living alone in itself is a major source of suffering in the elderly.[13] Studies have shown that loneliness results in increased mortality[14] and increased morbidity in the form of presence of higher number of chronic illness,[15] cardiovascular disease,[16],[17] and impaired cognitive functions.[18] Loneliness also significantly affects the mental health of an elderly. It leads to fear, anxiety, and depressive thinking. It increases the tendency of negative thinking, decreases self-confidence, decreases confidence on significant others, and increases the fear of being abused and secluded from the society.[3] Such a negative state can in turn lead to the development of depression.[19] Loneliness is also called as the “hidden killer” of the elderly. It has also been strongly linked with the development of suicidal ideations and parasuicidal behavior.[20]

Loneliness has been classified differently. Based on the various internal and external factors, three different types of loneliness has been described in the literature, namely, situational loneliness (loss of social contacts due to unexpected situations such as disasters, migration, and interpersonal conflicts), developmental loneliness (due to personal inadequacies, separation, poverty, and physical disability, etc.) and internal loneliness (due to certain personality factors, poor coping skills, low self-esteem, etc.).[21],[22] Loneliness is also conceptualized as emotional loneliness and social loneliness. While emotional loneliness arises when one starts becoming aware of missing/losing of a close attachment with a significant person (spouse, siblings) of one's life, social loneliness arises when one starts feeling aware of losing network of his/her social relationships in which he/she was a part in the past.[21] Studies have found marital status and availability of a good and supportive social network to be strong predictors of loneliness in the elderly.[23]

Studies have reported a strong association between loneliness and depression in the elderly population.[24] However, the cause and effect relationship between these two variables is not clear.[25] While some studies suggest that loneliness predicted subsequent intensifications in depressive symptomatology, but not the reverse,[25] other studies have revealed that a gradual increase in depressive symptoms predicted loneliness.[26] Some of the longitudinal studies on aging population in Western countries (Ireland, United States, and the Netherlands) have suggested that loneliness is an important factor in the genesis of elderly depression.[25],[27],[28] While the Irish study found loneliness to be a mediator in the association between social connectedness and depression.[27] A study from Chicago reported a temporal association between loneliness and depression, but this association was not attributable to the presence or absence of social networks.[25] A longitudinal study from the Netherlands found an independent effect of both loneliness and social connectedness (as measured by the quality of social networks) on the course of depression in the elderly.[28] In addition, the size/number of social network and the severity of loneliness emerged as the predictors of remission of depression in the elderly.[28] The difference in the findings of these studies suggests that there could be different conceptualizations of loneliness across different cultures.[29],[30]

There are limited data on loneliness from India. Few studies (with small sample sizes) from single centers have evaluated the relationship between loneliness, depression, and social connectedness among the elderly.[31],[32]

In this background, the present study aimed to evaluate the prevalence of loneliness and its relationship with social connectedness with depression in elderly. In addition, an attempt was made to evaluate the demographic and clinical predictors of loneliness and social connectedness in elderly patients with depression.

Methodology

This multicentric study was conducted under the aegis of the Indian Association for Geriatric Mental Health and was approved by all the local Institutional Ethics Committees of the institutes in which this study was conducted. All the participants were explained about the study and were recruited after obtaining written informed consent. Participants were recruited at 8 centers, details of which are already published earlier.[33]

The study followed a cross-sectional design in which participants were assessed only once. To be included in the study, patients of either gender, aged ≥60 years, fulfilling the criteria of major depressive disorder as per the Diagnostic and Statistical Manual of Mental Disorders-IV Edition criteria and confirmed by MINI Plus were recruited and those with mental retardation and those too ill to be assessed were excluded. All the patients were rated on Geriatric Depression Rating Scale (GDS-30), Generalized Anxiety disorder questionnaire (GAD-7), The Patient Health Questionnaire (PHQ-15), Columbia Suicide Severity Rating Scale (C-SSRS), UCLA LS, and Revised Social Connectedness Scale.

UCLA Loneliness Scale

This scale comprises 20 items, which evaluates the one's subjective feelings of loneliness as well as feelings of social isolation. These items reflect one's dissatisfaction from social relationships. The participants are required to assess each item in the scale according to how often they believe the statement is true for them on a 4-point scale, higher scores indicating more loneliness.[34] The scale has been shown have good internal consistency (coefficient a ranging from 0.89 to 0.94), test-retest reliability (r = 0.73), and adequate convergent and construct validity.[35] For this study, this scale was translated into Hindi.

Revised Social Connectedness Scale

This is a 20-item scale, of which 10 are positively worded and 10 are negatively worded. The 10 positively worded items capture the experience of sense of closeness with others and maintaining and seeking connections. The negatively worded items capture one's experience of distance and isolation from others. The scale has demonstrated adequate reliability (internal reliability α = 0.91, test-retest r = 0.96) and convergent and divergent validity.[36] Higher the score, better is the social connectedness. For this study, this scale was translated into Hindi.

Columbia Suicide Severity Rating Scale

The C-SSRS was designed to assess the full range (severity and intensity) of suicidal ideation and behavior. The severity and intensity of ideations is rated on a 5-point ordinal scale. Suicidal behavior subscale is rated on a nominal scale. Lethality subscale which assesses actual attempts and actual lethality is rated on a 6-point ordinal scale. The C-SSRS has been found to be reliable and valid in the identification of suicide risk in several research studies.[37],[38]

Data were analyzed using SPSS version 14 (SPSS for Windows, SPSS Inc., Chicago, IL, USA). Descriptive analysis involved calculation of mean and standard deviation (SD) with a range for continuous variables and frequency and percentages for ordinal or nominal variables. Chi-square test, t-test, and Mann–Whitney test were used for comparison of various variables. Pearson's correlation coefficient and Spearman's rank correlation coefficient were used to evaluate the association of loneliness and social disconnectedness with other variables.

Results

The study included 488 patients diagnosed with depression. Slightly more than half of the sample comprised of males (53.7%; n = 262), was on paid employment (53.3%, n = 260) and from urban locality (53.1%, n = 259). The mean age of the study sample was 66.55 (SD-5.83) years and the mean duration of education in years was 7.63 (SD 5.85). About one-fourth of the sample (25.4%; n = 124) were currently single (unmarried, widowed, separated, and divorced). About 70% of the sample had a nonnuclear family setup (69.9%, n = 341).

Three-fifths of the sample was diagnosed with first episode depression (60.9%; n = 297) and rest were diagnosed with recurrent depressive disorder (39.1%; n = 191). More than three-fourth of the sample had at least one comorbid physical illness (78.7%, n = 384). Comorbid psychiatric disorder and comorbid substance abuse were found in 3.1% and 37.9% of the study sample. The mean age of onset of depression was 60.2 (SD-10.5) years with a mean total duration of illness of 65.68 (SD-91.80) months. Family history of mental illness was found in 42.2% of the sample (42.2%, n = 206). Details are presented in [Table 1].

Severity of depression, anxiety, somatic symptoms, loneliness, and social connectedness

Mean scores on various scales are shown in [Table 2]. The mean GDS score was 16.96 (SD-24.03; range 10–30) with about one-fourth of the participants (n = 125; 25.6%) having severe depression as per GDS. The mean GAD-7 score of the sample was 9.46 (SD-4.20; range-0–21). On GAD-7, about four-fifths of the sample (81.6%) had scored ≥10, which is considered to be cutoff for diagnosis of GAD as per the GAD-7 scale. The mean total PHQ-14/15 score was 11.56 (SD-4.13; range-0–25) and about 70% of the sample had severe somatization (score >10). The mean social connectedness score of the sample was 69.87 (SD-10.20) with a range of 32–117 and the mean LS score was 27.93 (SD-13.96) with a range of 0–60.

The three-item UCLA LS (lack of companionship, left out in life, and isolated from others) have been most commonly used to assess the prevalence of loneliness across many studies and responses for any of these three items in the form of “sometimes/often” are considered as indicative of the presence of loneliness. In the present study, when the same method was followed, 77.3% of the entire sample reported the presence of loneliness. With respect to specific loneliness symptom, 62.5% reported lack of companionship, 58.7% reported left out in life, and 56.5% of the individuals reported felt isolated from others. There were no gender differences noted in the prevalence of any loneliness symptom. Details are mentioned in [Table 3].

Relationship between social connectedness scale and loneliness scale with depression, anxiety, and somatic symptoms

Higher loneliness scores had significant positive correlation with severity of depression, anxiety, and somatic symptoms as assessed by GDS-30, PHQ-15, and GAD-7, respectively [Table 4]. Higher social connectedness was associated with higher level of anxiety. However, no significant correlation emerged between severity of depression, somatic symptoms, and loneliness with social connectedness [Table 4].

Table 4: Relationship of social connectedness and loneliness with depression and anxiety in elderly patients with depression

When the association was evaluated separately for participants of either gender, as is evident from the [Table 4], loneliness had significant positive correlation with severity of depression, anxiety, and somatic symptoms across both the genders. In addition, in females, there was higher social connectedness was associated with more anxiety and lower loneliness.

Relationship of social connectedness and loneliness with demographic variables

There was no significant difference in the social connectedness score and loneliness score between male and female participants. Similarly, employment status and locality did not have any significant relationship with social connectedness and loneliness. However, participants who were currently single reported significantly higher loneliness (single: 32.90 [12.05] vs. married: 26.23 [14.18]; t-value: 4.687 [P < 0.001***]). Higher level of loneliness was reported by participants who were older (Pearson correlation coefficient: 0.151 (P < 0.001***). In terms of type of family, participants belonging to nuclear family reported significantly higher social connectedness (nuclear: 71.84 [12.85] vs. nonnuclear: 69.03 [8.71]; t-value: 2.81 [0.005**]). Higher social connectedness was reported by participants who were more educated (Pearson correlation coefficient: 0.214 (P < 0.001***).

Relationship of social connectedness and loneliness with clinical parameters

Social connectedness did not have any significant association with suicidal behaviors except for the fact that higher social connectedness was associated with higher number of aborted attempts (Spearman's correlation coefficient: 0.159, P < 0.001***) and presence of nonsuicidal behavior (t-value: 5.562, <0.001***).

Discussion

The present multicentric study which evaluated the prevalence of loneliness and its association with severity of depression and social connectedness in elderly individuals with depression shows that 77.3% of the elderly patients with depression experience loneliness. When the prevalence of loneliness is compared with the existing data, it is evident that the prevalence noted in the present study is much higher than that reported in general population studies from the developed countries, which have reported the prevalence of 11.5%–43%.[5],[6],[39],[40] The high prevalence in the present study could be due to the limitation of the study sample to elderly patients with depression.

The present study suggests that higher level of loneliness is associated with more severe depressive symptoms, anxiety symptoms, and somatic symptoms. Similar association between loneliness and depression has been documented in previous studies too.[29],[30],[31],[32] Some of the previous studies suggest that loneliness can be a risk factor for developing depression[7],[24] and it can increase the severity of depression[25],[27],[28] and it increases the risk for suicide in the elderly.[20],[41] Although the present study did not evaluate the cause-effect relationship, it can be said that higher level of depression leads to loneliness and vice-versa. The present study also shows that higher loneliness is associated both with suicidal ideations and number of suicidal attempts.

The present study suggests a positive and significant association between the depressive scores (as assessed on GDS-30 and PHQ-15) and loneliness scores. In addition, higher loneliness scores were significantly associated with nonspecific suicidal thoughts, active suicidal ideations with and without intent as well as with the presence of suicidal behavior. Accordingly, it can be said that, severity of depression can be reduced among elderly by avoiding loneliness. This can be done by providing social support as per the requirement. Further, the present study also suggests that clinicians evaluating elderly persons with depression must focus on the loneliness issues and try to enhance their social support. Association of loneliness with suicidal behavior also suggests the important role of improving social support of elderly, to reduce suicidal attempts in elderly with depression.

While some studies have found significant gender differences in the prevalence or severity of loneliness and depression, with higher loneliness among older females,[39],[42],[43],[44] but others have reported no significant differences between the two genders.[29],[31],[40] The present study supports the second set of studies and suggests that loneliness must be given equal importance in individuals of either gender.

In the present study too, there was significant association between loneliness and severity of anxiety. Very few studies have looked at the association between loneliness and anxiety symptoms in the elderly.[45],[46] It has been postulated that actual loss or fear of loss of interpersonal relationships/separation in the late life induces anxiety symptoms which may have several manifestations ranging from minor worry or grief to somatization/psychosomatic problems.[45] The association of loneliness and anxiety in elderly patients with depression can also possibly explain the higher prevalence of anxiety among elderly patients with depression.

Social connectedness has been found to be positively linked with a sense of subjective happiness and subsequently predicts lower loneliness and depressive symptoms.[47] However, few studies have found no relationship between sociability/social connectedness and loneliness.[31] The possible explanation could be feelings of loneliness does not depend only on the number of social networks but also depends upon the quality and satisfaction perceived by the individual.[31],[48] In the present study, surprisingly, loneliness was not associated with social connectedness among males, but the two variables had significant association among females, with lower social connectedness associated with higher level of loneliness among females. This finding can be understood from the sociocultural perspectives. Some of the studies suggest that after retirement, for persons of either gender, spousal support is the most important aspect of seeking social support. However, after spousal support, elderly men prefer to seek social support from same gender siblings and friends, whereas elderly women seek more support from their child and immediate family.[49] Accordingly, with changing social norms, in which the younger generation is more self-absorbed, seeks more independence, elderly females possibly experience more loneliness than men, who continue to maintain their social connectedness with same age siblings and friends.

The findings of the present study also suggest that higher loneliness is perceived by those, who age older and are currently single. This finding can be understood by the fact that, in elderly of either gender, spouse is possibly the most important part of their social network.[49],[50] Previous studies have also reported higher degree of loneliness and depression and anxiety symptoms in those who have no living children/separated from their children or living in old-age homes (commonly called as empty nest older adults).[51],[52],[53],[54] Accordingly, it can be said that as the elderly age, chances of losing spouse increases further, this increases the feelings of loneliness and depression.

Other factors which were found to have significant association with loneliness in the present study include the presence of comorbid physical illness. Previous studies have also demonstrated that social isolation/poor social connectedness and loneliness act as risk factors for the progression of physical illness and frailty[55],[56] and the association of loneliness and presence of a comorbid physical illness heightens the feelings of loneliness has also been reported earlier.[56] In the present study too, those with comorbid physical illness felt lonelier as compared to those without any comorbid physical illness. Hence, elderly individuals with depression with comorbid physical illness should be assessed more thoroughly for loneliness as it can further lead to aggravation of physical illness and subsequent increase in mortality due to gradual functional decline.[57],[58],[59]

Being married or being in a relationship has been found as a protective factor to prevent loneliness and subsequent depression across a number of studies.[60],[61],[62],[63],[64] In the present study also, higher scores of loneliness were found in those who were currently single (widowed/divorced/unmarried) and this finding supports the existing literature.

Some of the previous studies have reported association of loneliness with demographic variables such as security, occupation, locality, and income.[10],[29],[30],[31] However, in the present study, no significant association was noted between some of these variables and loneliness. This difference could be due to cultural factors or limitation of the present study sample to those who were currently depressed. Accordingly, these findings must be considered as preliminary and must be replicated.

The present study has certain limitations in the form of cross-sectional assessment, evaluation of clinic/hospital attending elderly population with depression. Extensive psychosocial assessment and interview to determine loneliness and social connectedness were not done and the reporting was limited to rating scales. Further, the present study design does not provide any understanding about the cause and effect relationship between depression, loneliness, and social connectedness. Strengths of the study include good sample size, recruitment of participants across multicentric centers spread across the country, and use of standardized instruments to assess depression, anxiety, loneliness, and social connectedness.

Conclusions

The present study suggests that about three-fourth of the elderly patients with depression also have associated loneliness. Loneliness is associated with higher severity of depression, anxiety, and somatic symptoms. Severity of depression is associated with loneliness but not with social connectedness. Lower social connectedness among elderly females with depression is associated with higher loneliness, but this is not true for elderly males with depression.

Caetano SC, Silva CM, Vettore MV. Gender differences in the association of perceived social support and social network with self-rated health status among older adults: A population-based study in Brazil. BMC Geriatr 2013;13:122.